HEALTH POLICY AND CLINICAL PRACTICE/REVIEW ARTICLE

Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions

Nathan R. Hoot, PhD Dominik Aronsky, MD, PhD
From the Department of Biomedical Informatics (Hoot, Aronsky) and the Department of Emergency Medicine (Aronsky), Vanderbilt University Medical Center, Nashville, TN.

Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identied the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identied 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, frequent-yer patients, inuenza season, inadequate stafng, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and nancial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda. [Ann Emerg Med. 2008;52:126-136.]
0196-0644/$-see front matter Copyright 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.03.014

INTRODUCTION
The international crisis of emergency department (ED) crowding has received considerable attention, both in political1,2 and lay3-7 venues. In 1986 the Emergency Medical Treatment and Labor Act mandated that all patients who present to an ED in the United States must receive a medical screening examination, regardless of their ability to pay.8 The unique role of the ED has prompted some to call it the safety net of the health care system.9,10 Unfortunately, the increasing problem of crowding has strained this safety net to the breaking point, according to a recent report by the Institute of Medicine.2,11 Escalation of the ED crowding problem has prompted researchers to investigate a number of scientic questions, some of which have been summarized by systematic literature reviews. One review characterized the diverse ways in which researchers have dened overcrowding.12 The authors found that the term has been frequently dened with various factors inside and outside of the ED and hospital. They concluded that the crowding research agenda would benet from a consistent denition. Another review characterized ambulance diversion, 126 Annals of Emergency Medicine

whereby an ED advises ambulances to transport patients to other nearby hospitals when possible.13 The authors found that ambulance diversion is a frequent reaction to ED crowding, which may carry consequences including delayed patient transport and lost hospital revenue. As noted by the Institute of Medicine, understanding the causes, effects, and solutions of the ED crowding problem is important.2 However, to the best of our knowledge, no previous systematic literature review has summarized this research. The objective of this review was to describe the scientic literature on ED crowding from the perspective of causes, effects, and solutions.

MATERIALS AND METHODS

Search Strategy We adopted the denition of the word crowding proposed by the American College of Emergency Physicians14: Crowding occurs when the identied need for emergency services exceeds available resources for patient care in the emergency department, hospital, or both. From this denition, we interpreted crowding to be a phenomenon that involves the
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Hoot & Aronsky interaction of supply and demand. We dened the scope of this review to include articles that met 4 criteria: (1) they studied causes, effects, or solutions of crowding as a primary objective; (2) they studied crowding on an empirical basis, with a description of the data collection and analysis methodology; (3) they studied crowding in the context of general emergency medicine, rather than a specialty service such as psychiatric emergency medicine; and (4) they studied everyday crowding, reecting a focus on daily surge rather than exceptional circumstances; in other words, they did not study crowding associated with disaster events. We identied a broad set of PubMed (MEDLINE) search terms to encompass each facet of the inclusion criteria. The search involved free text and Medical Subject Headings (MeSH) terms. We described the concept of ED by the following search terms: Emergency Medical Services[MeSH] OR Emergency Medicine[MeSH] OR emergency. We described the concept of crowding by the following search terms: Crowding[MeSH] OR crowding OR crowded OR overcrowding OR overcrowded OR diversion OR divert OR congestion OR surge OR capacity OR crisis OR crises OR occupancy. We queried MEDLINE on June 6, 2006, with the Boolean union of the above queries, restricting the search to English-language publications. Study Selection Two reviewers (N.R.H. and D.A.) independently examined the results returned by the MEDLINE search to identify potentially relevant abstracts. Articles that clearly did not meet one or more of the review criteria according to the title and abstract were not considered further. When the 2 reviewers disagreed, a consensus was reached through discussion. We retrieved full-text articles for the potentially relevant abstracts. The same 2 reviewers independently examined the full-text articles to determine which studies met all 4 of the inclusion criteria. Disagreements were again resolved through discussion to reach a nal consensus set of articles that met the review criteria. Data Collection and Processing We used a data extraction form (Appendix E1, available online at http://www.annemergmed.com) to record information about the methods and results of each relevant article, including study design, study setting, study population, sample size, independent variables, dependent variables, and primary ndings. We assigned the articles to nonexclusive groups according to whether they investigated causes, effects, or solutions of ED crowding. We attempted to represent the intentions of the original authors when assigning each article to a group. For example, an issue such as ambulance diversion may be considered a cause, effect, or solution of ED crowding, depending on the perspective of each study: it might be a cause of crowding at nearby institutions to which patients are diverted, it might be an effect of crowding at a single institution of interest, or it might be a solution of crowding by reducing
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Systematic Review of Emergency Department Crowding the patient load. Within the groups representing causes, effects, and solutions of ED crowding, we further categorized articles according to common themes that emerged among the primary ndings during the data abstraction phase. Assessment of Study Quality To assess the methodological quality of the studies, we applied a previously described 5-level instrument.15,16 Although it was originally developed to judge clinical trials, we applied the instrument consistently to clinical trials, descriptive studies, and surveys by using the following adaptation: Quality level 1 included prospective studies that studied a clearly dened outcome measure with a random or consecutive sample that was large enough to achieve narrow condence intervals and diverse enough to suggest generalizability of the ndings. Quality level 2 included prospective studies that were more limited in terms of sample size or generalizability. Quality level 3 included retrospective studies that otherwise would have satised the criteria for quality level 1 or 2. Quality level 4 included studies that sampled by convenience or other techniques that were prone to introduce bias. Quality level 5 included studies that lacked a clearly dened or validated outcome measure. We did not score articles that lacked necessary methodological details for the quality instrument.

RESULTS
The MEDLINE query returned 4,271 abstracts. The reviewers identied 188 abstracts for full-text retrieval, of which 93 articles satised the criteria for inclusion in the review. A ow diagram of the selection process is presented in the Figure 1. The rate of reviewer agreement during the abstract screening phase, before consensus discussion, was 93% overall, 76% among included articles, and 94% among excluded articles. The statistic for chance-corrected agreement between the 2 reviewers was 0.47 (95% condence interval: 0.42 to 0.52), denoting moderate agreement.17 We found that quality level 1 contained 14 articles, quality level 2 contained 12 articles, quality level 3 contained 47 articles, quality level 4 contained 10 articles, and quality level 5 contained 6 articles. Four articles were not scored because of inadequate reporting of methodology. The primary ndings of all articles are summarized briey in the following sections. The methods and results of each high-quality prospective study are described in Table 1. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. This sum exceeds 93 because some articles were assigned to multiple categories as necessary. Causes Three general themes existed among the causes of ED crowding: input factors, throughput factors, and output factors. These themes correspond to a conceptual framework for studying ED crowding.18 Input factors reected sources and aspects of patient inow. Throughput factors reected
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Systematic Review of Emergency Department Crowding

Hoot & Aronsky Stockholm experienced a 21% increase in ED visits during a 4-year span, far exceeding the population growth of 4.5% during the same period; the authors attributed this to 2 hospital closures that caused the ED to become more responsible for primary care delivery.29 One study estimated that excess patient volume prompted 71% of ambulance diversion episodes, and excess patient acuity prompted 15% of ambulance diversion episodes.30 Although recently discharged inpatients accounted for just 3% of total visits to one ED, they had longer lengths of stay and more frequent hospital admissions than other patients.31 California EDs that were located in neighborhoods of lower socioeconomic status had increased waiting times, estimated to be 10 minutes longer per $10,000 reduction in per capita income.32 Throughput factors. We identied inadequate stafng to be a commonly studied throughput factor that may cause crowding. Three articles discussed inadequate stafng: A point prevalence study of crowding found that the average nurse was caring for 4 patients simultaneously, and the average physician was caring for 10 patients simultaneously.33 A study in California showed that lower stafng levels of physicians and triage nurses predisposed patients to wait longer for care.32 By contrast, a time series analysis indicated that, after controlling for other factors, ambulance diversion was not associated with physician and nurse stafng levels.34 Three articles discussed other aspects of throughput factors: During a 9-year period, the number of California EDs decreased by 12%, whereas the number of ED beds increased by 16%.35 This increase may not have been sufcient, considering that the number of visits and critical visits per ED increased by 27% and 59%, respectively, during the same period. The training background of the attending physician in charge of an ED has been independently associated with patients leaving without being seen.36 The use of ancillary services, including computed tomographic (CT) scanning and other procedures, prolonged the ED length of stay among surgical critical care patients.37 Output factors. We identied inpatient boarding and hospital bed shortages to be commonly studied output factors that may cause crowding. Five articles studied inpatient boarding: One study found that half of EDs in the United States reported extended boarding times for patients in the ED.38 A point prevalence study found that 22% of all ED patients were boarding at one time.33 One academic ED delivered 154 patient-days of care to critically ill patients during a 1-year period.39 Patients experiencing access block, dened by boarding time exceeding 8 hours, was associated with increased diversion, waiting times, and occupancy level in an Australian ED.40 A time series analysis showed that the number of boarding patients was independently associated with the frequency of ambulance diversion.34 Six articles examined hospital bed shortages: A study of English accident and emergency trusts found a strong
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Figure 1. Study selection process. Articles were dened to be relevant if they (1) studied causes, effects, or solutions of ED crowding as a primary objective; (2) provided a description of the data collection and analysis; (3) took place in a general adult or pediatric ED setting; and (4) focused on everyday crowding instead of disaster-related crowding. Both phases of study selection involved a consensus between 2 independent reviewers.

bottlenecks within the ED. Output factors reected bottlenecks in other parts of the health care system that might affect the ED. The commonly studied causes of crowding are summarized in Table 2. Input factors. We identied nonurgent visits, so-called frequent-yer patients, and the inuenza season to be commonly studied input factors that may cause crowding. Four articles considered nonurgent visits: Three studies found that low-acuity ED patients frequently sought nonurgent care in the ED, and their reasons for doing so included insufcient or untimely access to primary care.19-21 However, one analysis suggested that visits by patients with nonurgent complaints were not associated with the most severe crowding at large hospitals.22 Two articles studied frequent-yer patients: One report found that frequent visitors, dened by 4 or more annual visits, accounted for 14% of the total ED visits.23 Moreover, these patients generally did not have urgent complaints and exhibited Andersens24 need factors for health care. A similar report found that the 500 most frequent users of one ED accounted for 8% of total visits, and 29% of these visits might have been appropriate for primary care.25 Three articles investigated the inuenza season: Los Angeles County hospitals recorded a 4- to 7-fold increase in ambulance diversion during the peak 4 weeks of u season compared with other times of the year.26 In Toronto, every 10 local cases of u resulted in a 1.5% increase in the fraction of ED visitors who were elderly u patients.27 The same group in Toronto calculated that every 100 local cases of u resulted in an increase of 2.5 hours per week of ambulance diversion.28 Four articles examined other aspects of input factors: 128 Annals of Emergency Medicine

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Table 1. Methods and results of each high-quality prospective study.
Article Focus Design Sample Outcome Measures

Systematic Review of Emergency Department Crowding

Primary Findings

Quality level 1 Andersson, Cause 200129 Bayley, 200570 Burt, 200664 Effect

Prospective 16,246 patients observational during 3 y

Effect

Eckstein, 200472 Fromm, 199339 Haines, 200695 Lambe, 200332

Effect

Cause

Solution

Cause

Neely, 199456 Effect Patel, 200691 Solution

Shah, 200694

Solution

Shaw, 199876 Solution

Solberg, 2003105 Vilke, 200492

Solution

Solution

Weiss, 200499 Solution Quality level 2 Baker, 199167 Effect

ED visits increased from 247.8 to 287.7 per 1,000 population, waiting time increased by 8.2 min for nonreferred patients Prospective 904 patients Marginal cost 825 patients boarded more than 3 h, opportunity cost of cohort $204 per boarding patient, annual total of $168,300 for hospital Survey 405 EDs Ambulance diversion 16.2 million ambulance transports in United States, 501,000 diversion events annually, 70% from large EDs, 85% response rate Prospective 21,240 incidents Time to unload patient 1 in 8 transports took at least 15 min to unload patient, observational of out of increasing over time, more frequent from January to service March Prospective 17,900 visits ED length of stay 8.5% of ED patients were critically ill, remained in ED for cohort 145.3 min; 154 patient-days of critical care were administered Prospective 704 incidents of Hospital admission rate, Paramedic decision to not transport pediatric patients led case series non-transport patient satisfaction to a 2.4% admission rate, no deaths, good patient satisfaction Prospective 1,798 patients Waiting time Waiting times averaged 56 min, each $10,000 decrease observational in local per-capita income increased waiting times by 10.1 min Prospective 481 patients Transport distance, time Diverted patients traveled 5.0 to 11.6 min longer and 1.3 observational to 4.6 miles further than nondiverted patients Before-after 3y Ambulance diversion Community-wide diversion policy decreased diversion intervention hours by 74%, despite increases of 6.5% in census and 8.8% in admissions Before-after 2 mo Ambulance diversion Destination-control program reduced diversion hours by intervention 41% at a university hospital and 61% at a community hospital Before-after 48,669 children Elopement, waiting time Additional personnel called on 32% of days, waiting time intervention decreased by 15 min, elopement rate decreased by 37% Delphi method 74 experts Magnitude estimation 38 consensus measures of patient demand and complexity; ED capacity, efciency, and workload; hospital efciency and capacity Before-after 2y Ambulance diversion Standardized diversion guidelines reduced diversion hours intervention from 4,007 to 1,079 and diverted patients from 1,320 to 322 Prospective 336 observations Staff assessments of NEDOCS predicted crowding assessments with R2 of 0.49, reduced model retained 88% of accuracy observational crowding Prospective cohort Prospective cohort 397 patients Triage assessment, self- 46% of patients who left without being seen needed reported health immediate medical attention, 11% were hospitalized in status, hospitalization the next week Waiting time, self15% of patients left without being seen, 86% because of reported health status waiting time, doubled risk of worse pain or disease severity ED length of stay Additional physician during evening shift decreased length of stay from 176137 to 14186 min for outpatients Reason for ambulance 30.4% of ambulance diversion incidents caused by entry diversion block, 13.6% by access block, 27.2% by both, 15.2% by high acuity Reason for visit, 45% of patients cited barriers to primary care, 13% had willingness to seek urgent complaints, 38% would trade visit for primary alternate care care appointment Elopement, ambulance Acute care unit decreased patient elopement from 10.1% diversion to 5.0% and ambulance diversion from 6.7 to 2.8 h per 100 patients ED utilization Frequent-yer patients decreased ED usage after primary care referral, health education, and counseling, P.01 for each

Waiting time, ED length of stay

Bindman, 199169 Bucheli, 200474 Fatovich, 200330 Grumbach, 199319

Effect

700 patients

Solution Before-after 360 patients intervention Cause Prospective 141 incidents of observational diversion Cause, Survey solution 700 patients

Kelen, 200178 Solution Before-after 1,589 patients intervention Michelen, 200696 Solution Before-after 711 patients intervention

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Systematic Review of Emergency Department Crowding

Table 1. (Continued) Methods and results of each high-quality prospective study.
Article Raj, 2006
103

Hoot & Aronsky

Focus

Design

Sample

Outcome Measures

Primary Findings

Solution Prospective 128 observations Staff assessments of observational crowding Solution Cause, effect Solution

Reeder, 2003100 Schneider, 200333 Vilke, 200490

Washington, 200285

Solution

Mean difference of 3.47 NEDOCS units between NEDOCS and staff assessments, 95% agreement limits of 46.52 to 53.43 Prospective 221 observations Staff assessments of READI bed ratio differed by 0.245, acuity ratio by 0.131 observational crowding between periods of normal and excess demand Survey 250 EDs Operating status at 4.2 patients per nurse, 9.7 patients per physician, 11% index time of EDs diverting, and 22% of patients boarding, 36% response rate Before-after 3 wk Ambulance diversion Frequency of ambulance diversion decreased from 27.7 intervention to 0 h when nearby hospital stopped diverting ambulances Randomized 156 patients Self-reported health Patients with 3 symptom complexes deferred to next-day controlled status, care utilization care had similar health status and care utilization at trial follow-up

READI, Real-time Emergency Analysis of Demand Indicators; NEDOCS, National Emergency Department Overcrowding Scale.

correlation between ED treatment time and hospital occupancy.41 A period of widespread hospital restructuring in Toronto independently increased the rate of severe crowding from 0.5% to 6% of the time.42 Length of stay in one ED increased substantially when the hospital occupancy levels exceeded 90%.43 A survey of Korean EDs linked high hospital occupancy levels to ED crowding.44 A study in Portland found that a decrease in the number of hospital beds was strongly associated with an increase in ambulance diversion.45 Another study estimated that a hospital closure would affect the nearest ED by increasing ambulance diversion by 56 hours per month for 4 months.46 Additional themes. Five surveys and interviews identied factors that health care providers and other stakeholders perceive to be important causes of ED crowding: increasing patient volume and acuity, shortages of treatment areas, shortages of nursing staff, delays in ancillary services, boarding inpatients, and hospital bed shortages.47-51 Effects Four general themes existed among the effects of ED crowding: adverse outcomes, reduced quality, impaired access, and provider losses. Adverse outcomes reected health-related patient endpoints. Reduced quality reected benchmarks of the care delivery process. Impaired access reected the ability of
Table 2. Commonly studied causes of ED crowding.
Cause of Crowding Input factors Nonurgent visits Frequent-yer patients Inuenza season Throughput factors Inadequate stafng Output factors Inpatient boarding Hospital bed shortages References 19-22 23,25 26-28 32-34 33,34,38-40 41-46

patients to receive timely care at their preferred institutions. Provider losses reected consequences borne by the health care system itself. The commonly studied effects of crowding are summarized in Table 3. Adverse outcomes. We identied patient mortality to be a commonly studied adverse outcome of crowding. Four articles focused on patient mortality: One study found a signicant increase in mortality associated with weekly ED volume.52 High occupancy in one Australian ED was estimated to cause 13 patient deaths per year.53 Another study associated a combined measure of hospital and ED crowding with an increased risk of mortality at 2, 7, and 30 days after hospital admission.54 In Houston, a statistically insignicant trend was found for higher mortality among trauma patients who were admitted during ambulance diversion.55 Reduced quality. We identied transport delays and treatment delays to be commonly studied effects of crowding pertaining to reduced quality. Four articles examined transport delays: Ambulance diversion was shown to increase transport time and distance in 2 studies.56,57 A study focused on cardiac patients found that the 90th percentile of transport time increased when multiple local hospitals were on diversion.58 During 2 years in which crowding was exacerbated in Toronto, the 90th percentile of
Table 3. Commonly studied effects of ED crowding.
Effect of Crowding Adverse outcomes Patient mortality Reduced quality Transport delays Treatment delays Impaired access Ambulance diversion Patient elopement Provider losses Financial effect References 52-55 56-59 60-63 33,64 36,65-69 70,71

130 Annals of Emergency Medicine

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Hoot & Aronsky transport time increased by 11%.59 Four articles investigated treatment delays: Patients who arrived at one ED during crowded periods waited 30 minutes longer for an ED bed.60 Crowding was associated with increased door-to-needle time for patients with suspected myocardial infarction.61 High ED occupancy levels were associated with delayed pain assessment and lower likelihood of pain documentation among hip fracture patients.62 A trial with negative results found no increase in the time to head CT among patients with suspected stroke when a trauma evaluation occurred simultaneously.63 Impaired access. We identied ambulance diversion and patient elopement to be commonly studied effects of crowding pertaining to impaired access. Two articles focused on ambulance diversion: A national survey found that approximately 501,000 ambulance diversions occurred in the United States during 1 year, and approximately 70% of these were from large EDs.64 A point-prevalence study of ED crowding found that 11% of US EDs were simultaneously diverting ambulances.33 Six articles characterized patient elopement: Patients were more likely to leave without being seen when ED occupancy exceeded 100% of the total capacity.36 In one study, the rate of patients leaving without being seen closely correlated with waiting times.65 The rate of patients leaving one ED without being seen correlated well with a crowding regression model.66 Among patients who left without being seen, 46% needed urgent medical attention, and 11% were hospitalized within a week.67 Patients frequently cited long waiting times as a reason for leaving without being seen, and 60% of them sought other medical care within a week.68 Patients who left the ED without being seen were twice as likely to report worsened health problems.69 Provider losses. We identied nancial effect to be a commonly studied provider loss of crowding. Two articles calculated nancial effect: One study estimated that the hospital lost $204 in potential revenue per patient with an extended boarding time.70 Another study found that patients who boarded in the ED longer than a day also stayed in the hospital longer, increasing costs by an estimated $6.8 million during 3 years.71 Two articles considered other aspects of provider losses: A study found that during 1 in 8 patient transports, the ambulance could not unload the patient promptly at the ED, putting it out of service for 15 minutes or more.72 A survey of Canadian emergency physicians found that job dissatisfaction was closely related to the perceived scarcity of resources.73 Additional themes. Three surveys identied outcomes that ED directors perceive to be major effects of crowding: death, delayed care, unnecessary procedures, and extended pain.47-49 Solutions Three general themes existed among the solutions of ED crowding: increased resources, demand management, and operations research. Increased resources reected the
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Systematic Review of Emergency Department Crowding

Table 4. Commonly studied solutions of ED crowding.
Solution of Crowding Increased resources Additional personnel Observation units Hospital bed access Demand management Nonurgent referrals Ambulance diversion Destination control Operations research Crowding measures Queuing theory References 74-76 77-80 81,82 19,85-87 88-92 93,94 98-105 106,107

deployment of additional physical, personnel, and supporting resources. Demand management reected methods to redistribute patients or encourage appropriate utilization. Operations research reected crowding measures and ofine change management techniques. The commonly studied solutions of crowding are summarized in Table 4. Increased resources. We identied additional personnel, observation units, and hospital bed access to be commonly studied solutions of crowding involving increased resources. Three articles studied additional personnel: One described a permanent increase in the number of physicians during a busy shift, reducing the outpatient length of stay by 35 minutes.74 A rural hospital, which previously did not have an attending physician present during the night shift, found that the presence of an attending physician improved several throughput measures of ED crowding.75 One hospital activated reserve personnel as needed during the viral epidemic season, reducing the waiting time by 15 minutes and the rate of patients leaving without being seen by 37%.76 Four articles investigated observation units: One short-stay medical unit reduced the length of stay for outpatients with chest pain and asthma exacerbation.77 Another study found that an ED-managed acute care unit decreased ambulance diversion by 40% and halved the rate of patients leaving without being seen.78 A hospital reported that the addition of an acute medical unit reduced the median number of boarding patients from 14 to 8 during a 2-year period.79 One study proposed a hybrid observation unit, which was designed to use resources effectively and substantially decreased the length of stay for scheduled procedure patients.80 Two articles considered hospital bed access: After increasing the number of critical care beds from 47 to 67, ambulance diversion at one hospital decreased by 66%.81 A natural experiment resulting from a period of industrial action, leading to improved hospital bed access for an ED, resulted in signicant decreases in occupancy levels and waiting times.82 Two articles examined other aspects of increased resources: One study increased both space and stafng through an ED reorganization, which resulted in the improvement of several crowding outcomes.83 Another study attempted to reduce the potential bottleneck of ancillary services by implementing pointAnnals of Emergency Medicine 131

Systematic Review of Emergency Department Crowding of-care laboratory testing, which decreased the length of stay by 41 minutes.84 Demand management. We identied nonurgent referrals, ambulance diversion, and destination control to be commonly studied solutions of crowding involving demand management. Four studies tested nonurgent referrals: A survey of ED patients found that 38% would swap their ED visit for a primary care appointment within 72 hours.19 A randomized, controlled trial focused on 3 common symptom complexes and found that they may be deferred for next-day primary care without worsening self-reported health status on follow-up.85 When following up nonurgent patients who were triaged to receive care elsewhere, one group found that there were no major adverse outcomes, and 42% of the patients received sameday care elsewhere.86 A similar study found that 94% of nonurgent patients who were referred to community-based care reported that their condition was better or unchanged.87 Five studies investigated ambulance diversion: By one calculation, ambulance diversion decreased the rate of ambulance arrivals by 30% to 50%.88 A similar calculation found that red-alert ambulance diversion reduced the arrival rate by 0.4 per hour.89 When one hospital committed to avoiding ambulance diversion for 1 week, the need for diversion at a nearby hospital was almost eliminated.90 Standardized diversion criteria in Sacramento, targeted to decrease roundrobin crowding, reduced the rate of ambulance diversion by 74% despite increased patient volume.91 San Diego implemented a standardized policy for initiating ambulance diversion among all local hospitals and reduced ambulance diversion by 75%.92 Two studies proposed destination control: The use of Internet-accessible operating information to redistribute ambulances reduced the need for diversion from 1,788 hours to 1,138 hours in one network.93 Another study described a physician-directed ambulance destination control initiative that reduced diversion by 41%.94 Three studies considered other aspects of demand management: A trial of paramedic-initiated nontransport found that 2.4% of nontransported pediatric patients were later admitted to the hospital.95 Three social interventions designed for frequent visitors, which included education and counseling, were associated with decreased ED utilization.96 Another study targeted frequent users with case management interventions, but the rate of ED utilization was unchanged.97 Operations research. The studies within the operations research theme did not describe direct solutions to ED crowding; however, they proposed to support solutions through improved business intelligence. We identied crowding measures and queuing theory to be commonly studied solutions to crowding according to operations research. Eight studies described crowding measures: The Emergency Department Work Index (EDWIN) associated well with ambulance diversion and less well with secondary outcome measures at its institution of origin.98 The National Emergency 132 Annals of Emergency Medicine

Hoot & Aronsky Department Overcrowding Scale (NEDOCS) explained 49% of the variation in physician and nurse assessments of crowding.99 The Real-time Emergency Analysis of Demand Indicators were designed for real-time monitoring of ED operations, although they did not correlate with providers opinions on crowding.100 The Work Score predicted ambulance diversion at its institution of origin with area under the receiver operating characteristic curve of 0.89.101 A comparative validation, which used staff assessments of crowding as the outcome, estimated the area under the receiver operating characteristic curve of the EDWIN to be 0.80 and of the NEDOCS to be 0.83.102 However, an external validation of the NEDOCS in Australia concluded that it was not useful, according to Bland-Altman and statistics.103 A sampling form consisting of 7 operational measures was shown to correlate well with staff assessments of crowding.104 A panel of experts described 38 consensus operational measures that may be used to assess crowding levels.105 Two studies used queuing theory: One group illustrated the ability of discrete event simulation to model ED operations, and they tested its applicability by analyzing a proposed triage scheme.106 A similar study described a separate discrete event simulation and studied the effects of physician utilization on patient waiting times.107 Additional themes. Five studies described multifaceted administrative interventions that could not be classied separately: A broad intervention consisting of 51 actions reduced ED length of stay and ambulance diversion in Melbourne.108 One network deployed several interventions, tuned for the individual needs of 4 hospitals, and reduced the amount of ambulance diversion by 25% and 34% in consecutive years.109 A group of hospitals in Rochester deployed several interventions, and they reported that the most effective interventions occurred outside the ED.110 Another study reported interventions, including more physicians, improved ancillary services, and changes in hospital policy, that reduced length of stay by half.111 One hospital deployed a multipronged intervention, which involved a short-stay unit, additional physicians, and an early warning system, to deal with holiday demand surges.112

LIMITATIONS
This study has a number of limitations that merit discussion. First, we may not have captured every article that studied causes, effects, and solutions of ED crowding. We limited the search to English-language articles, so any relevant articles published in foreign languages were not included. We avoided searching the grey literature with a general purpose internet query, and we did not hand-search the references of included articles. If used, these 2 techniques might have impaired the reproducibility of our review. We searched a single database; moreover, it is possible that our search terms did not capture all aspects of the topic. The MeSH vocabulary contains a single term related to crowding, so we supplemented the search with a large set of free-text keywords. We attempted to minimize the likelihood of missed articles by applying a broad search strategy.
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Hoot & Aronsky We also used a conservative approach during the abstract screening phase, retrieving the full-text articles for all abstracts that could not be clearly excluded. The moderate value may be explained because one author was more conservative than the other in marking abstracts for full-text retrieval. This issue was identied and resolved during the consensus discussion. We believe our methodology captured the majority of pertinent articles. Second, the diversity of methodology, outcome measures, and reporting among the original articles rendered aspects of this review difcult. We attempted to describe the primary ndings of each study as consistently as possible, noting the effect sizes of each study when feasible and in other cases describing the nature of the ndings in more qualitative terms. In some cases, our descriptions were limited according to the reporting of the original articles. The brief summaries that we provide do not capture the full complexity of each study, so our review is intended to guide interested readers to the original cited articles. We did not conduct a formal meta-analysis, because of the breadth of study designs and endpoints considered. We refrain from making strong conclusions about which factors are most important because these would be based primarily on judgment rather than numeric inference. Third, the classication of studies into groups and themes was partly subjective, so objections may be made regarding how particular articles were categorized. We acknowledge that there may be no clearly correct taxonomy for grouping this diverse set of articles. For instance, measurement tools and queuing models would not reduce ED crowding unless paired with an intervention plan. Regardless, we have classied these articles as solutions, insofar as the original authors intended their research to support crowding interventions. Our intention in using this trichotomy of causes, effects, and solutions was to provide a structured overview of the relevant literature, which we hope benets the reader.

Systematic Review of Emergency Department Crowding operational changes involve the entire department, rather than individual patients who may be randomized to experimental and control groups.85 We believe that the crowding literature would benet from more randomized controlled trials examining patient-focused interventions. Although several studies investigated nonurgent and frequent-yer visits, relatively little evidence suggests they independently cause ED crowding.19-23,25 This notion is supported by recent literature.113 More evidence is available to identify inpatient boarding and other hospital-related factors as causes of ED crowding.33,34,38-46 These studies corroborate with successful interventions that reduced crowding by altering the operation of hospital and community services other than the ED.78,79,81,82,90-93 We believe that the crowding literature would benet from more studies that analyze the ED in the context of integrated hospital processes and focus on multicenter community networks rather than single institutions. The results suggest that standard operations management tools, such as queuing theory, have only recently been applied in an effort to improve ED patient ow.106,107 We are aware of few previous reports describing such applications in the ED setting.114 By contrast, these tools were adopted much earlier by industries like airlines and manufacturing. This lag is analogous to the gap between basic science and clinical science, which translational research aims to address. A result of queuing theory states that a system with varying inputs and xed capacity will become congested for transient periods.115 By consequence, permanent increases in resources may be neither efcient nor adequate to address crowding, given the uctuating demand. The review includes 1 study demonstrating the feasibility of deploying additional resources on demand to alleviate ED crowding.76 We believe that the crowding literature would benet from studies that apply standard management research techniques to ED operations and investigate ways to alter resource availability dynamically according to demand. When considered as a whole, the body of literature demonstrates that ED crowding is a local manifestation of a systemic disease. The causes of ED crowding involve a complex network of interwoven processes ranging from hospital workow to viral epidemics. The effects of ED crowding are numerous and adverse. Various targeted solutions to crowding have been shown to be effective, and further studies may demonstrate new innovations. This broad overview of the current research may help to inform the future research agenda and, subsequently, to protect the fragile safety net of the health care system.
Supervising editor: David J. Magid, MD, MPH Funding and support: By Annals policy, all authors are required to disclose any and all commercial, nancial, and other relationships in any way related to the subject of this article, that might create any potential conict of interest. See the Manuscript Submission Agreement in this issue for examples of specic conicts covered by this statement. Dr. Hoot was Annals of Emergency Medicine 133

DISCUSSION
A substantial body of literature exists describing the causes, effects, and solutions of ED crowding. The major themes among the causes of crowding included nonurgent visits, frequent-yer patients, inuenza season, inadequate stafng, inpatient boarding, and hospital bed shortages. The major themes among the effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and nancial effect. The major themes among the solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The quality instrument that we used indicated that a large number of high-quality articles have been published about ED crowding.15,16 We identied a total of 26 prospective studies and 47 retrospective studies that met the criteria for the 3 highest quality levels. We noted a scarcity of randomized controlled trials in this review, perhaps because many ED
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supported by National Library of Medicine grant LM07450-02 and National Institute of General Medical Studies grant T32 GM07347. The research was also supported by National Library of Medicine grant R21 LM009002-01. The authors declare no conicts of interest pertaining to the publication of this work. Publication dates: Received for publication July 16, 2007. Revision received January 26, 2008. Accepted for publication March 11, 2008. Available online April 23, 2008. Earn CME Credit: Continuing Medical Education for this article is available at: www.ACEP-EMedHome.com. Reprints not available from the authors. Address for correspondence: Nathan R. Hoot, PhD, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232; 615-936-3720, fax 615-936-1427; E-mail nathan.hoot@vanderbilt.edu. REFERENCES
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38. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980-986. 39. Fromm RE Jr, Gibbs LR, McCallum WG, et al. Critical care in the emergency department: a time-based study. Crit Care Med. 1993;21:970-976. 40. Fatovich DM, Nagree Y, Sprivulis P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351-354. 41. Cooke MW, Wilson S, Halsall J, et al. Total time in English accident and emergency departments is related to bed occupancy. Emerg Med J. 2004;21:575-576. 42. Schull MJ, Szalai JP, Schwartz B, et al. Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years. Acad Emerg Med. 2001;8: 1037-1043. 43. Forster AJ, Stiell I, Wells G, et al. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10:127-133. 44. Hwang JI. The relationship between hospital capacity characteristics and emergency department volumes in Korea. Health Policy. 2006;79:274-283. 45. Warden CR, Bangs C, Norton R, et al. Temporal trends in ambulance diversion in a mid-sized metropolitan area. Prehosp Emerg Care. 2003;7:109-113. 46. Sun BC, Mohanty SA, Weiss R, et al. Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004. Ann Emerg Med. 2006;47:309-316. 47. Derlet RW, Richards JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J. 2002;95:846-849. 48. Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001;8:151-155. 49. Richards JR, Navarro ML, Derlet RW. Survey of directors of emergency departments in California on overcrowding. West J Med. 2000;172:385-388. 50. Clark K, Normile LB. Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic states. J Emerg Nurs. 2002;28:489-495. 51. Bazzoli GJ, Brewster LR, Liu G, et al. Does U.S. hospital capacity need to be expanded? Health Aff (Millwood). 2003;22: 40-54. 52. Miro O, Antonio MT, Jimenez S, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999;6:105-107. 53. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184:213-216. 54. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208-212. 55. Begley CE, Chang Y, Wood RC, et al. Emergency department diversion and trauma mortality: evidence from Houston, Texas. J Trauma. 2004;57:1260-1265. 56. Neely KW, Norton RL, Young GP. The effect of hospital resource unavailability and ambulance diversions on the EMS system. Prehosp Disaster Med. 1994;9:172-176. 57. Redelmeier DA, Blair PJ, Collins WE. No place to unload: a preliminary analysis of the prevalence, risk factors, and consequences of ambulance diversion. Ann Emerg Med. 1994; 23:43-47.

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58. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department gridlock and out-of-hospital delays for cardiac patients. Acad Emerg Med. 2003;10:709-716. 59. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ. 2003;168:277-283. 60. Liu S, Hobgood C, Brice JH. Impact of critical bed status on emergency department patient ow and overcrowding. Acad Emerg Med. 2003;10:382-385. 61. Schull MJ, Vermeulen M, Slaughter G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577-585. 62. Hwang U, Richardson LD, Sonuyi TO, et al. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006;54:270275. 63. Chen EH, Mills AM, Lee BY, et al. The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke. Acad Emerg Med. 2006;13: 349-352. 64. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47:317-326. 65. Kyriacou DN, Ricketts V, Dyne PL, et al. A 5-year time study analysis of emergency department patient care efciency. Ann Emerg Med. 1999;34:326-335. 66. Weiss SJ, Ernst AA, Derlet R, et al. Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005;23:288-294. 67. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. JAMA. 1991;266:10851090. 68. Rowe BH, Channan P, Bullard M, et al. Characteristics of patients who leave emergency departments without being seen. Acad Emerg Med. 2006;13:848-852. 69. Bindman AB, Grumbach K, Keane D, et al. Consequences of queuing for care at a public hospital emergency department. JAMA. 1991;266:1091-1096. 70. Bayley MD, Schwartz JS, Shofer FS, et al. The nancial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005; 45:110-117. 71. Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12:265-266. 72. Eckstein M, Chan LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med. 2004;43:100-105. 73. Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthc Manag. 2005;50:327-340. 74. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician stafng. Eur J Emerg Med. 2004;11:2934. 75. Donald KJ, Smith AN, Doherty S, et al. Effect of an on-site emergency physician in a rural emergency department at night. Rural Remote Health. 2005;5:380. 76. Shaw KN, Lavelle JM. VESAS: a solution to seasonal uctuations in emergency department census. Ann Emerg Med. 1998;32:698-702. 77. Bazarian JJ, Schneider SM, Newman VJ, et al. Do admitted patients held in the emergency department impact the

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throughput of treat-and-release patients? Acad Emerg Med. 1996;3:1113-1118. Kelen GD, Scheulen JJ, Hill PM. Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion. Acad Emerg Med. 2001;8:1095-1100. Moloney ED, Bennett K, ORiordan D, et al. Emergency department census of patients awaiting admission following reorganisation of an admissions process. Emerg Med J. 2006; 23:363-367. Ross MA, Naylor S, Compton S, et al. Maximizing use of the emergency department observation unit: a novel hybrid design. Ann Emerg Med. 2001;37:267-274. McConnell KJ, Richards CF, Daya M, et al. Effect of increased ICU capacity on emergency department length of stay and ambulance diversion. Ann Emerg Med. 2005;45:471-478. Dunn R. Reduced access block causes shorter emergency department waiting times: an historical control observational study. Emerg Med (Fremantle). 2003;15:232-238. Miro O, Sanchez M, Espinosa G, et al. Analysis of patient ow in the emergency department and the effect of an extensive reorganisation. Emerg Med J. 2003;20:143-148. Lee-Lewandrowski E, Corboy D, Lewandrowski K, et al. Implementation of a point-of-care satellite laboratory in the emergency department of an academic medical center. Impact on test turnaround time and patient emergency department length of stay. Arch Pathol Lab Med. 2003;127:456-460. Washington DL, Stevens CD, Shekelle PG, et al. Next-day care for emergency department users with nonacute conditions. A randomized, controlled trial. Ann Intern Med. 2002;137:707714. Derlet RW, Nishio D, Cole LM, et al. Triage of patients out of the emergency department: three-year experience. Am J Emerg Med. 1992;10:195-199. Diesburg-Stanwood A, Scott J, Oman K, et al. Nonemergent ED patients referred to community resources after medical screening examination: characteristics, medical condition after 72 hours, and use of follow-up services. J Emerg Nurs. 2004; 30:312-317. Lagoe RJ, Hunt RC, Nadle PA, et al. Utilization and impact of ambulance diversion at the community level. Prehosp Emerg Care. 2002;6:191-198. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban, and rural areas of Central Maryland. Acad Emerg Med. 2001;8:36-40. Vilke GM, Brown L, Skogland P, et al. Approach to decreasing emergency department ambulance diversion hours. J Emerg Med. 2004;26:189-192. Patel PB, Derlet RW, Vinson DR, et al. Ambulance diversion reduction: the Sacramento solution. Am J Emerg Med. 2006;24: 206-213. Vilke GM, Castillo EM, Metz MA, et al. Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial. Ann Emerg Med. 2004;44:295-303. Sprivulis P, Gerrard B. Internet-accessible emergency department workload information reduces ambulance diversion. Prehosp Emerg Care. 2005;9:285-291. Shah MN, Fairbanks RJ, Maddow CL, et al. Description and evaluation of a pilot physician-directed emergency medical services diversion control program. Acad Emerg Med. 2006;13: 54-60. Haines CJ, Lutes RE, Blaser M, et al. Paramedic initiated nontransport of pediatric patients. Prehosp Emerg Care. 2006;10: 213-219.

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96. Michelen W, Martinez J, Lee A, et al. Reducing frequent yer emergency department visits. J Health Care Poor Underserved. 2006;17(1 suppl):59-69. 97. Lee KH, Davenport L. Can case management interventions reduce the number of emergency department visits by frequent users? Health Care Manag (Frederick). 2006;25:155-159. 98. Bernstein SL, Verghese V, Leung W, et al. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938-942. 99. Weiss SJ, Derlet R, Arndahl J, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004;11:38-50. 100. Reeder TJ, Burleson DL, Garrison HG. The overcrowded emergency department: a comparison of staff perceptions. Acad Emerg Med. 2003;10:1059-1064. 101. Epstein SK, Tian L. Development of an emergency department work score to predict ambulance diversion. Acad Emerg Med. 2006;13:421-426. 102. Weiss SJ, Ernst AA, Nick TG. Comparison of the National Emergency Department Overcrowding Scale and the Emergency Department Work Index for quantifying emergency department crowding. Acad Emerg Med. 2006;13:513-518. 103. Raj K, Baker K, Brierley S, et al. National Emergency Department Overcrowding Study tool is not useful in an Australian emergency department. Emerg Med Australas. 2006; 18:282-288. 104. Weiss SJ, Arndahl J, Ernst AA, et al. Development of a site sampling form for evaluation of ED overcrowding. Med Sci Monit. 2002;8:CR549-553. 105. Solberg LI, Asplin BR, Weinick RM, et al. Emergency department crowding: consensus development of potential measures. Ann Emerg Med. 2003;42:824-834. 106. Connelly LG, Bair AE. Discrete event simulation of emergency department activity: a platform for system-level operations research. Acad Emerg Med. 2004;11:1177-1185. 107. Chin L, Fleisher G. Planning model of resource utilization in an academic pediatric emergency department. Pediatr Emerg Care. 1998;14:4-9. 108. Cameron P, Scown P, Campbell D. Managing access block. Aust Health Rev. 2002;25:59-68. 109. Lagoe RJ, Kohlbrenner JC, Hall LD, et al. Reducing ambulance diversion: a multihospital approach. Prehosp Emerg Care. 2003; 7:99-108. 110. Schneider S, Zwemer F, Doniger A, et al. Rochester, New York: a decade of emergency department overcrowding. Acad Emerg Med. 2001;8:1044-1050. 111. Cardin S, Alalo M, Lang E, et al. Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions? Ann Emerg Med. 2003; 41:173-185. 112. Salazar A, Corbella X, Sanchez JL, et al. How to manage the ED crisis when hospital and/or ED capacity is reaching its limits. Report about the implementation of particular interventions during the Christmas crisis. Eur J Emerg Med. 2002;9:79-80. 113. Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49:257-264. 114. Siddharthan K, Jones WJ, Johnson JA. A priority queuing model to reduce waiting times in emergency care. Int J Health Care Qual Assur. 1996;9:10-16. 115. Gross D, Harris CM. Fundamentals of Queuing Theory. New York, NY: Wiley; 1985.

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#: _____________ Author: _______________________ Year: _________ Quality: ________ Reason: ________________________ __ ____________________ Design: ________________________ _______________________________________ Institution: _____________________________________________________________ Volume: __________ Acuity System: ___________ Trauma Level: _________ Population: ________________________ ____________________________________ Sample: _______________________________________________________________ Endpoint: ______________________________________________________________ Analysis: ______________________________________________________________ Causes: _______________________________________________________________ Effects: _______________________________________________________________ Solutions: _____________________________________________________________ Notes: ________________________________________________________________
Appendix E1. Data extraction form
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